Healthcare Provider Details

I. General information

NPI: 1831942416
Provider Name (Legal Business Name): CARSON SAMUEL JORDAN I DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 CENTRAL AVE W
WIGGINS MS
39577-2434
US

IV. Provider business mailing address

1725 CENTRAL AVE W
WIGGINS MS
39577-2434
US

V. Phone/Fax

Practice location:
  • Phone: 601-928-9095
  • Fax: 601-928-9383
Mailing address:
  • Phone: 601-928-9095
  • Fax: 601-928-9383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1394
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: